This is A371 of PCT/IT99/00331 filed Oct. 19, 1999.
The present invention relates to a pharmaceutical/nutritional composition for supporting and/or providing therapy to individuals at risk and/or under treatment for dysfunctions of energy metabolism, and specifically, for mitochondrial diseases.
More specifically, the present invention relates to a composition comprising (a) an amount of a lipid-soluble benzoquinone selected from the group consisting of ubiquinone (Coenzyme Q10, CoQ10), its reduced form, ubiquinol-10 (CoQ10H2) or mixtures thereof, effective for performing a therapeutical and/or preventive and/or nutritional activity, and (b) at least a further component suitable for stimulating and enhancing the intramitochondrial transportation of component (a), the resulting composition being potently effective for the prevention and/or treatment of mitochondriopathies.
Accordingly the composition may take the form and exert the action of a dietary or nutritional supplement or of an actual medicine, depending upon the support or preventive action, or the strictly therapeutic action, which the composition is intended to exert in relation to the particular individuals it is to be used in. Depending on the actual circumstances, the composition of the present invention need not or, alternatively, should be taken under the supervision of an attending physician.
In the publication by the United Mitochondrial Disease Foundation, xe2x80x9cAbout Mitochondria and Diseasexe2x80x9d (http:/ibiochemgen.ucsd.edu/umdf/AboutMitoDisease.htm), which is incorporated herein by reference, the following definition of what a mitochondrial disease is, and what the triggering, sub-cellular causes are, is given:
xe2x80x9cThe mitochondria produce adenosine triphosphate (ATP), the body""s mobile energy source. When mutations occur which affect the mitochondria, the vital supply of ATP is disrupted, less and less energy is generated within the cell. When this process is repeated on a large scale throughout the body, whole systems begin to fail, and the life of the person in whom this is happening can be compromised, changed or even ended. The cells that require the most energy, like the brain, heart and skeletal muscles, are the most vulnerablexe2x80x9d.
This reference also provides a detailed list and description of mitochondrial diseases, which encompasses, inter alia, Co-enzyme Q10 deficiency; Complex III deficiency (Ubiquinonexe2x80x94cytochrome c oxidoreductase deficiency) whose symptoms include pigmentary retinopathy; Complex IV deficiency/COX deficiency (cytochrome c oxidase deficiency) whose symptoms include optic atrophy and ophthalmoplegia; CPEO (Chronic Progressive External Ophthalmoplegia Syndrome) whose symptoms include visual myopathy and retinis pigmentosa; ARMD (Age-Related Macular Degeneration); NARP (Neuropathy, Ataxia and Retinis pigmentosa) and many others.
Since CoQ10 is indispensable to cellular bionergetics, its deficiency may bring about a host of pathologies.
Indeed, CoQ10 is known to play an essential role as an electron (redox) carrier in the mitochondrial electron transport chain of the cell. However, it also protects membrane phospholipids and those in LDL from peroxidation as well as protects and/or regenerates vitamin E. CoQ10 is synthesized in the body from precursors of cholesterol synthesis and therefore is not classed as a vitamin. However, the ability to synthesize CoQ10 decreases with age and there may be an increasing dependence on food to supply the nutrient. The most abundant sources are fresh unprocessed foods, particularly meats, fish, nuts and seed oils. The average daily intake of CoQ10 is approximately 2 mg.
Ubiquinol-10 or CoQ10H2, the reduced form of CoQ10, plays a second role as a potent lipid-soluble antioxidant and its activity at physiological concentrations in the lipid components of cells has recently been shown.
CoQ10""s antioxidative, electron transport, and membrane-stabilizing properties have widely been investigated aiming at prevention of and/or treatment of various cardiovascular diseases, including prevention of cellular damage during reperfusion, angina pectoris, hypertension, myocardial ischemia, and congestive heart failure.
In patients with mitochondrial encephalomyopathy, CoQ10 treatment increases mitochondrial functions and exercise performance, and reduces the acidosis associated with exercise. This finding is consistent with CoQ10 participation in electron transport and mitochondrial membranes, and in the biological oxidation of cellular fuels for energy generation.
CoQ10 deficiency was also reported to be associated with viral infections, and supplementation of CoQ10 in acquired immune deficiency syndrome (AIDS) patients resulted in enhanced macrophage activity and increased serum level of IgG. CoQ10 treatment has been reported to provide some benefits in cancer patients, and enhanced hematopoietic activity in malnourished children. All the evidence suggests that CoQ10 may play essential roles in maintaining and promoting health, under normal and abnormal conditions.
It has become more and more apparent that individuals at risk and/or under treatment for mitochondriopathies are in need of increased supplementation of ubiquinones with respect to the normal intake of these substances through the diet, since particularly CoQ10 deficiency may cause the onset, precipitate or aggravate the symptoms of a serious mitochondriopathy.
Many efforts have been made over the last decade in order to find formulations that would increase the bioavailability of CoQ10 or anyhow enhance its efficacy at the cellular organelle sites of action. For instance, M. Weis et al in xe2x80x9cBioavailability of four oral Coenzyme Q10 formulations in healthy volunteers (Molec. Aspects Med. Vol. 15 [supplement] pps 273-s 280, 1994) report on a four-way randomised cross-over trial wherein the bioavailability of four different CoQ10 formulations was compared. The study results suggest that a soy bean oil suspension of CoQ10 (Bioquinon(copyright), 100 mg CoQ10 with 400 mg of soy bean oil in soft gelatine capsules) exhibits the highest bioavailability.
However, in spite of all these efforts, no satisfactory formulations able to provide a therapeutical or preventive effective concentration of ubiquinons and particularly of CoQ10 at their intracellular sites of action, have been developed to-date.
Polyunsaturated fatty acids (PUFA) are subdivided in classes based on the location of the first double bond counting from the methyl end of the fatty acid molecule: xcfx89-3 (or n-3) fatty acids have their first double bond between the third and fourth carbon atoms, and the (xcfx89-6 (or n-6) fatty acids have their first double bond between the sixth and seventh carbon atoms. Particularly importante are the xcfx89-3 fatty acids and, specifically, linolenic acid (18:3 xcfx893) (LNA), eicosapentaenoic acid (20:5 xcfx893) (EPA), and docosahexaenoic acid (22:6 xcfx893) (DHA), wherein the first number (before the colon) gives the number of carbon atoms in the molecule and the second gives the number of double bonds.
In the last two decades, epidemiologic studies, clinical investigations and animal experiments have expanded our knowledge of the properties of dietary fatty acids in health and disease, growth and development. As a recent result of these investigations, the focus is on the ratio of xcfx89-6/xcfx89-3 fatty acids in the diet; the essentiality of xcfx89-3 fatty acids and their metabolic effect in the prevention and treatment of chronic diseases. These biological and functional effects of xcfx89-3 fatty acid exert profound beneficial metabolic changes in coronary heart disease, hypertension, non-insulin-dependent diabetes mellitus, inflammatory and autoimmune disorders, and possibly cancer. For a detailed account on the sources, metabolism, biological and functional effects and dietary aspects of xcfx89-3 fatty acids see e.g. xe2x80x9cFunctional Foodxe2x80x9d edited by Israel Goldberg, Chapman and Hall (1994), Chapter 16: xe2x80x9cFatty Acidsxe2x80x9d by Artemis P. Simopoulos, pp 355-392, which is incorporated herein by reference.
We have now found that a combination composition comprising in admixture:
(a) a lipid soluble benzoquinone selected from the group consisting of Coenzyme Q10, (CoQ10), its reduced form, ubiquinol-10 (CoQ10H2) or mixtures thereof, in an amount effective for performing a therapeutical and/or preventive and/or nutritional activity in a human need thereof; and
(b) at least one omega-3 polyunsaturated fatty acid or an ester thereof, is able to enhance the pharmacological/nutritional effects of CoQ10 and/or CoQ10H2.
Although it is neither intended nor necessary to rely on any theoretical interpretation to account for the aforesaid enhanced effects, it is apparent that, most likely, they are due to the omega-3 poly-unsaturated acid acting as bioactive vehicles for CoQ10 and/or CoQ10H2 and boosters of the intramitochondrial transportation thereof to their sites of action.
The omega-3 polyunsaturated acid is selected from the group consisting of eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), linolenic acid (LNA) or mixtures thereof. EPA and DHA or mixtures thereof are particularly preferred. Preferred esters of LNA, EPA or DHA are the triglycerides and the ethyl ester.
The composition may also comprise saturated, monoinsaturated, omega-6 and omega-9 fatty acids or mixtures thereof. Examples of such acids are palmitic acid (16:0), oleic acid (18:1 xcfx899), linoleic acid (18:2 xcfx896), and arachidonic acid (20:4 xcfx896) or mixture thereof. If one or more of these non omega-3 fatty acids are present, the amount of the aforesaid omega-3 fatty acids, particularly EPA and/or DHA, preferably exceeds 65% and is lower than 95% by weight of the overall mixture of omega-3 fatty acids.
The weight ratio DHA:EPA in the composition ranges from 1:1 to 1:20, preferably from 1:1 to 1:5.
The weight ratio (b):(a) in the compostion ranges from 1:20 to 1:50.
The composition of the present invention may further comprise xcex1-tocopherol (vitamin E) as component (c). Preferably, the weight ratio (b):(c) in the composition ranges from 1:20 to 1:50. We have found that the aforesaid omega-3 fatty acids act as bioactive vehicles towards Vitamin E as well, i.e. they enhance the parmacological effects of Vitamin E.
The efficacy of the compositions according to the present invention towards many forms of mitochondriopathies and the ability of the same compositions to enhance the intramitochondrial transportation of CoQ10 was shown in clinical trials. As an istance of the successful treatment of a mitochondriopathy, a study on patients affected by photophobia and ARMD is reported hereinbelow.
The following retinal model for assessing mitochondriopathy was used.
As known, reactive oxigen species (ROS) may be generated at least at three sites in the retina:
in the photoreceptor cell during light stimulation.
in the retinal pigmented epithelium (RPE), which phagocitize photoreceptor discs during normal turnover and light stimulation.
in the neuroretina at the synaptosomes.
In each of these three sites, mitochondria are the common source and target of ROS.
We found that in the normal retina, mitochondrial membranes of the photoreceptor cells have significantly different molecular structure than those of the outer segment discs. The mitochondrial membranes are more basophilic, and they contain more unsaturated lipids than the disc membranes of the outer segments. Further, in vitro studies of normal human photoreceptors cells showed, that the behaviour of mitochondrial and disc membranes is different when they are exposed to oxido-reductive stress. The same oxidative stress which resulted in reversible alteration of the disc membranes, caused irreversible damage of the mitochondrial membranes. However, the exposure to strong electron donor substances (chlorpromazines) slighly altered the structure of mitochondrial membranes, but it disrupted the disc membranes in dose dependent manner. These findings suggested that mitochondrial membranes are more sensible to oxidative, while disc membranes are more sensible to reductive influences.
Via electron microscopic studied on diseased human retinas, we showed that mitochondrial damage is a typical alteration in age-related macular degeneration (ARMD), myopic retinal dystrophies (NRD) and in retinitis pigmentosa (RP). Mitochondrial alterations included loss of the cristae, accumulation of intramitochondrial lipid droplets, swollen of the mitochondria, and decrease in number of them were observed in diseased RPE and photoreceptors cells. Pigment epithelial cells were predominantly affected in ARMD and MRD, while in RP both photoreceptor and pigmented epithelial cells were seriously altered.
These findings suggested that the retina is a suitable model for assessing mitochondriopathy.
We performed open, controlled studies of the various compositions of CoQ10 and alpha tocopherol with or without the addiction of omega-3 fatty acids. In each series of healthy volunteers and photophobia patients the treatment was applied for one month, while in the series of ARMD patients it was for three months. To evaluate visual function before and after treatment, as well as after one month of xe2x80x9cwash-outxe2x80x9d macular photostress test was applied.
Macular Photostress Test: 60 seconds bright light illumination to one eye (the follow eye was covered) by standardized slit lamp (full aperture and maximum intensity of a Haag-Streit slit lamp). Contrast sensitivity was tested by Maffei decimal chart before and after the illumination and the recovery time was measured (i.e. measured the time when the eye was able to read the same figure, as before the photostress). This function of the retina depends on the metabolic support to light stimulation-regeneration, thus a very suitable method for evaluate mitochondrial functions (Wu, G., Weiter, J. J., Santos, S., Ginsburg, L., Villalobos, R.: The macular photostress test in diabetic retinopathy and age-related macular degeneration. Arch. Ophthalmol., 108, 1556-58 (1990).
Blood levels of total, HDL, and LDL cholesterol and triglicerid levels were evalutated before, after three months of treatment, and after one month xe2x80x9cwash-outxe2x80x9d in the ARMD group.
12 healthy volunteers were enrolled in this clinical trial (6 male, 6 female, aged 24-37 years, mean body weight 66,5 kg).
1st group: treated with 50 mg CoQ10 granulated+70 mg vitamin E/day
2nd group: treated with 100 mg CoQ10 granulated+70 mg vitamin E/day
3rd group: treated with 30 mg CoQ10 in soy bean oil+30 mg vitamin E/day
4th group: treated with 30 mg CoQ10 in omega-3 ( greater than 65% conc.)+30 mg Vitamin E/day
Results
healthy volunteers react very poorly to these treatments;
pharmacological effect of 50 mg CoQ10 granulated+vitamin E was insignificant;
lipid addition improved dose-efficacy relation of CoQ10+vitamin E (100 mg. CoQ10 granulated were equivalent 30 mg of CoQ10 dissolved in soy bean oil);
highly concentraded PUFA was the most effective treatment.
16 patients suffered from photophobia were entrolled in this trial (11 female, 5 male, aged 23-44 years, mean body weight 63,4 kg).
1st group: treated with 100 mg CoQ10 granulated+70 mg vitamin E/day
2nd group: treated with 30 mg CoQ10 in soy bean oil+30 mg vitamin E/day
3rd group: treated with 30 mg CoQ10 in fish oil ( greater than 30% conc.)+30 mg vitamin E/day
4th group: treated with 30 mg CoQ10 in omega-3 ( greater than 65% conc.)+30 mg Vitamin E/day
Results
The pharmacological effect of CoQ10+vitamin E was approximately double in cases of photophobia than in healthy volunteers.
omega-3 enhances intensity and duration of the parmacological effects of CoQ10+vitamin E;
higher concentration of omega-3 was showed better effects than lower concentration: the differences were 50% after one month of treatment, and approximately 30% after one month of xe2x80x9cwash-outxe2x80x9d.
43 patients affected by early age-related macular degeneration (visual acuity better than 20/40) were involved in these studies (23 female, 20 male, aged between 55-66 years, mean body weight 66,8 kg).
1st group: treated with lutein+zeaxantin+vitamin E (a commercially available product)
2nd group: treated with 1.000 mg omega-3 ( greater than 65%) only
3rd group: treated with fish oil+30 CoQ10+30 mg vitamin E/day
4th group: treated with omega-3 ( greater than 65%)+30 mg CoQ10+30 mg Vitamin E/day
Results
There were no significant differences between the groups treated with a commercially available dietary supplement (containing lutein, zeaxantin and vitamin E) and omega-3 ( greater than 65%) alone.
CoQ10+vitamin E in highly concentrated omega-3 was more effective than fish oil+CoQ10+vitamin E, after 3 months (50%) and after one month of wash-out (30%);
highly concentrated ( greater than 65%) PUFA showed synergistics pharmacological effects with CoQ10 and vitamin E, superior than those of low concentration PUFA or saturated lipids;
highly concentrated ( greater than 65%) PUFA administration showed lowering of the plasma triglyceride levels and improved the ratio of total/HDL cholesterol, which was not observed in fish oil (30% omega-3) treated cases. In contrary, in 3 of the 12 cases, increase of total cholesterol and/or triglicerid levels were observed.
Conclusions
These pharmacological studies showed that CoQ10+vitamin E in a vehicle of highly concentrated polyunsaturated fatty acids improved retinal function, primarily the regeneration of photoreceptor cells in normal conditions and in diseases states.
The most likely cellular target of these substances is the mitochondria of photoreceptor cells. The longer duration of visual improvement, a particularly important pharmacological effect, indicates that the composition of the present invention achieves a higher intracellular concentration of CoQ10 and/or higher affinity of this substance to the target organelles than those accomplished via the usual enterally administrable CoQ10-containing formulations at present commercially available.